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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 06/03/2025
Date Signed: 06/03/2025 12:43:16 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241112125326
FACILITY NAME:BEACH TERRACE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306005901
ADMINISTRATOR:ERIC JENSENFACILITY TYPE:
740
ADDRESS:12282 BEACH BOULEVARDTELEPHONE:
(530) 242-8300
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 48DATE:
06/03/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Christine Chon- Executive DirectorTIME COMPLETED:
12:42 PM
ALLEGATION(S):
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Neglect of care and supervision that resulted in the resident's condition that required medical intervention.
Facility has pests.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of delivering the complaint investigation findings into the above allegations. LPA met with Executive Director (ED) Christine Chon and explained the reason for the visit.

On November 12, 2024, the Department received a complaint regarding the neglect/lack of care and supervision of Resident #1 (R1) and pests concerns at the facility. The investigation was initiated by the Department on November 14, 2024. During the course of the investigation, the Department toured the facility, interviewed six residents, ten staff, one witness, and R1’s representative, and obtained the following documentation: Resident/Staff Rosters, Care Staff Assignment dated November 9, 2024, Staff Schedule, Incident Report, Face Sheet, Resident Assessment, Needs and Services Plan, Physician’s Report, Narrative Charting, and medical records.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 22-AS-20241112125326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BEACH TERRACE ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306005901
VISIT DATE: 06/03/2025
NARRATIVE
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Regarding the allegation, neglect of care and supervision that resulted in the resident’s condition requiring medical intervention, the investigation revealed the following: R1 was admitted to the facility in the memory care unit on October 18, 2024, and was placed on hospice on October 2, 2024, prior to moving into the facility. R1 has a diagnosis of Senile Degeneration of the Brain, Atrial Fibrillation, and high blood pressure. R1 required full assistance such as transfers, escorting, and toileting per the Needs and Services Plan dated October 18, 2024. Per interviews conducted, four out of nine staff reported that the status checks were conducted every two hours and more if resident is a fall risk. The service plan notes R1 not requiring additional status checks although the facility staff were informed R1 routinely getting up at least two to three times to use the bathroom in the middle of the night at the time. Staff #2 (S2) was informed of the night routine during the pre-appraisal assessment conducted at R1’s home on October 7, 2024 at 3pm.

On November 9, 2024, at approximately 8:03am, a caregiver discovered R1 in a prone position suspended from the bed rail by the neck. Per medical reports on page 200, dated November 9, 2024, R1 had sustained an unwitnessed fall in the evening, however the time of fall and the exact length of time R1 was suspended is unknown. During the investigation, it was determined that that residents are assigned to staff for monitoring. Staff #4 (S4) was assigned to check on R1 every 2 hours. S4 stated that they checked R1 at 2:30am on November 9th. Based on S4’s statement, S4 admitted not following the facility policy requiring them to check on the resident every two hours. The facility staff did not document the checks, and there was no way to verify that the checks were actually completed.

After discovering R1 suspended, the caregiver notified Staff #1 (S1) reporting a “headlock,” and S1 arrived at the room at about 8:07am. S1 immediately attempted to reach Staff #2 (S2) by phone three times but was unsuccessful and subsequently called Staff #3 (S3) via FaceTime to report the incident. S3 instructed S1 not to move R1 and to call 911 instead. Paramedics arrived approximately 8:34am and discovered R1 in the same position, while the staff, instead of freeing the resident, were observed clearing the live ants from R1’s face, mouth, and body. Emergency Medical Services (EMS) reported that R1’s airway had been obstructed by the rail causing R1’s oxygen levels to drop and their face and neck to swell. Page 68 of the medical report dated November 10, 2024, confirms R1’s oxygen saturation was at 81% at the time of assessment and improved to 93% after R1 was placed on a non-rebreather mask.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20241112125326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BEACH TERRACE ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306005901
VISIT DATE: 06/03/2025
NARRATIVE
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Per Mayo Clinic, a healthy oximeter values often range from 95%-100% with values under 90% are considered low. Based on the medical assessment, page 129 indicates that R1 was diagnosed with acute respiratory failure with hypoxia and hypercarbia and sepsis which is contributed by impaired ventilation.

Regarding the allegation, Facility has pests, LPA toured the facility during the initial visit conducted on November 14th, and no immediate health and safety threats were identified at the time of inspection. LPA observed live ants in the unit that R1 used to reside in and observed ants in other residents’ rooms. Based on the interviews, five out of ten staff interviewed confirmed the presence of ants in the facility. Out of the nine interviewed, three staff witnesses, and the medical responders who were present on scene witnessed the ants covering R1’s mouth, face, and body. Additionally, five out of the six residents interviewed witnessed ants in their respective rooms. The medical responders witnessed three staff trying to clean the ants from R1's face and body. Page 135 of the medical report also corroborates “ants crawling all over” R1.

The investigation revealed that there were substantial evidence corroborating neglect/lack of care and supervision of R1 as staff failed to conduct their routine checks, initiate the 911 call timely, and to provide immediate rescue measures to aide in R1 who was in a painful position covered in live ants for an unknown amount of time throughout the night and continued to be in the same position for approximately 30 minutes after being discovered by staff.

Therefore, based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Neglect of care and supervision that resulted in the resident’s condition that required medical intervention and Facility has pests are deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations.

Deficiencies are being cited on the attached LIC 9099D, and an immediate Civil Penalty (CP) is being assessed. See the attached LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) as per Health & Safety Code 1569.49(f).

An exit interview was conducted with Executive Director Christine Chon, and a copy of this report including the LIC9099-Cs, LIC9099-D, LIC421IM, LIC811s, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20241112125326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BEACH TERRACE ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306005901
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/04/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
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Executive Director stated proof of in-service training covering routine checks, documentations of endorsements, appropriate/immediate actions during a life-threatening emergency and non-emergency situations to ensure safety and survival and an Acknowledgement of Understanding for the said deficiency will be submitted to LPA via email by POC due date.
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Based on the Department’s interviews and record review, facility staff did not conduct routine checks and provide immediate rescue measures at the time R1 was discovered which poses an immediate Health and Safety risk to persons in care.
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Type A
06/04/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary… at all times.

This requirement is not met as evidenced by:
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The pest control has serviced monthly treatmenmts following the incident. Executive Director indicated that an Acknowledgement of Understanding of the said deficiency will be submitted to LPA via email by POC due date.
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Based on observation, interviews, and record review, three witness staff and medical responders witnessed the ants covering R1’s mouth, face, and body which poses a potential Health and Safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4